Infecting the Treatment: Being an HIV-Positive Analyst (Book Review)

Author:  Cole, Gilbert
Publisher: The Analytic Press
Reviewed By: Andrew Suth, PhD, Vol. XXVII, 1 (Winter 2007), pp. 75-76

Gilbert Cole’s, Infecting the Treatment: Being an HIV-Positive Analyst is a thorough and well-reasoned discussion of the personal, relational and political ethics of disclosing serostatus as an HIV positive person. A main theme of Gilbert Cole’s thought-provoking book is the complexity of disclosure of HIV status in the analytic treatment. At one point, he discusses the desire to keep vestiges of the disease hidden for fear of being discovered. At the same time he struggles with the implications of keeping hidden an essential part of his own subjectivity, especially if it is to be discovered later in less forthright ways. As he adeptly puts it,

When the serostatus of the analyst is revealed after the symptoms are observable, the question from the analysand’s point of view might be, “How could you have conducted my analysis while keeping this from me?” Conversely, in the event that the analyst reveals seropositivity to the analysand before any apparent physical change, the question might be, “How can you expect me to continue in treatment while knowing this about you?” (p. 81)

He later goes on to understand this conflict using Ehrenberg (1995) and Greenberg (1995) to point out, “The salient question in the relational–conflict model is not whether or not to make a particular disclosure—or, once one is (inadvertantely or otherwise) made, how to correct this mistake—but what is the best use that can be made of that disclosure” (p. 89).

It is within this context that I thought of how powerful is the topic upon which Cole embarks. At points when I was reading the book, I found myself self-conscious. How would it be interpreted that I had a copy of a book about an HIV-positive analyst? In fact, the author speaks of the powerful nature of “guilt by association” in considering how this taboo topic is handled gingerly in analysis when he discusses the implication of leaving a book on his side table that discusses HIV health. He wondered if there was some unconscious motivation in leaving this book out; however, he also considered how the same question goes unanalyzed for books of a different nature. For me, I found that topic stimulating my own fantasies of what I was trying to convey or hide in different settings: in my office, on the train, at the coffee shop. Elements of my professional as well as social self were challenged by books about HIV unlike the thousands of other books I have toted around everywhere I go.
On one occasion, I had the book out a few minutes prior to seeing a particular patient who has struggled both with issues of loss and with issues of my sexuality. We have worked with how this discovery impacts him and how it challenges his ability to idealize me as a man. It has also provided an opportunity to learn more about my humanity, and I am certain it had the effect of enriching the relationship rather than tainting it. Given this context along with a significant history of loss of significant relationships, I was aware of the possible impact of the patient seeing a book about a very particularly dangerous and meaning-laden virus out as my current reading material. With this in mind, I discreetly put the book away minutes before the session began but was not unaware of the compromises I was making in doing so.

It was this vignette that made me consider two key elements in discussing Gilbert Cole’s dialogue about HIV. The first, the meaning of taboo in relation to illness, is wonderfully laid out. The second is the inherently political nature of HIV.

The idea that HIV and its disclosure are a potential contaminant in the treatment is ably discussed. Chapter 1, “Knots of Meaning,” unpacks associations with certain subjectivities of the analyst including sexual orientation and HIV status as well as the impact of disclosure, both overt and inadvertent, on the therapeutic relationship. He continues with this discussion in a more personal way in Chapter 2, “The HIV-Positive Analyst.” Cole explores HIV positivity as a mark of vulnerability as well as a sign of the sexualization and, in fact, penetration of the individual. Themes of infection, penetrated barriers, and invasion of foreign bodies into the self are explored, as in the following passage, “The phenomenon of AIDS forms an intersection with masculine fantasies concerning interiority that carry particular salience in the question of the construction of identity. Anxieties about the other that is inside have long been a masculine preoccupation” (p. 41). He proceeds to discuss, in a more classically analytic vein, that this may represent an envy of the generativity of women. In fact, it could also be understood as a representation of the male way of relating that is particularly autonomous and boundaried when compared with “woman’s ways of knowing” (Jordan, 1997; Belenky et al., 1986).

In a particularly interesting section, Cole examines the potential stigma and/or identity that form(s) in relation to one’s serostatus. In expanding the discussion from binary opposites to ranges of meaning that fluctuate (positive/negative vs. non-progressive, asymptomatic, on medication . . .), the meaning of the disease is understood to encompass not only sexuality but also masculinity, virulence, passivity/activity, immunity and even one’s status as of, or above humanity which is often so important in treatment. It is here where the idea of identity in its full form is best illuminated in a discussion of HIV. Dr. Cole does an excellent job of articulating Goffman’s ideas about stigma and reinterpreting them within a relational context to comprehend the importance of HIV status in outlining a personal element of the analyst’s subjectivity and in turn provides an important contribution to the understanding of the transference.

The rest of the book is dedicated to exploring the implications of HIV status on identity and relational dynamics within the treatment. As Cole suggests, the project he embarks upon explores the personal, the social, the sexual, and the political nature of identity and meaning within the transference. Chapter 3 more fully discusses the ethics and implications of disclosure in the analytic situation, and Chapter 4 advances the ethical argument as is implied in its well-conceived title, “A Duty to Disclose?” As such, it speaks to an understanding of ethics that is complicated. To come out as HIV positive to a patient may lead to undue burden injected by the analyst; to abstain could be tantamount to betrayal where the essence of one’s being and the promise that the analyst will be fully human with respect to his role in the relationship is challenged. One way of understanding this is the fear of the “other.” In this case, death is an “other” as is HIV or sexual orientation. What is at play is a connection between the otherness of death and the otherness of HIV. In order to navigate this foreign land, therapy must involve an “ethics of mutuality” that mediates between the parts that are familiar and the parts that are foreign (Shabad, 2001). It suggests that we are not given the luxury of deciding if we disclose our subjectivity without paying an ethical consequence. In our work, if we are truly considered to be experts in relatedness and stimulating agency, it is also our ethical responsibility to refrain from protecting others from their own perceived fragility. Cole’s handling of this dilemma is adept. While he seems at times to spend too much energy detailing the history of transference and disclosure, he can be forgiven for what feels somewhat like defensiveness in outlining his position. That is, psychoanalysis has always tread lightly regarding the analyst’s own subjective desires. This is true to a far greater extent when those desires are same-sexed (p. 20). Dr. Cole astutely points out that the connection between viral infection and same-sex sexuality is charged for psychoanalysis.

It is here where HIV status and discussion of disclosure traverses the personal to land squarely in the political. This book makes a political statement: one suggesting that gay people, after a long struggle to hold a place at the table, now must demand the full respect and range of human experience, from the bedroom to the treatment room, from the cradle to the grave, just as our straight colleagues have asserted in their radical transformation of the analytic situation as a relational endeavor (Mitchell, 1988a). Gilbert Cole has furthered that argument in his openness to analyzing his subjective experience and respecting his patients for their ability to accept him as part of the full range of humanity. What might be further explored is the explicitly political nature of this disease. While the social implications are clear, there is an element of activism in the utterance of one’s serostatus that must also be interpreted.

In Chapter 5, Dr. Cole invites a small group of colleagues to share their experience of being HIV-positive analysts. There is not space in this review to fully consider his contribution to hermeneutic research as a natural extension of analytic thought. In this limited space, however, it is important to note that psychoanalysis is at its core concerned with meaning making. Work like Cole’s, with small Ns that are analyzed narratively, provides a needed infusion of empirical data beyond the analytic treatment situation. Those of us dedicated to qualitative analytically informed research should applaud the extensive literature and conceptual framework for this project.

The final chapter is an ambitious attempt to tie together many themes within a western philosophical tradition dating to Plato. It comes off as a bit confusing and tangential as probably would necessarily be the case when trying to achieve this type of project within one final chapter. Again, I forgive some confusion for the thrill of contextualizing this debate as part of the long history of philosophical and analytic thought rather than allowing it to be dismissed as marginalized.

What Cole is able to do with his work is impressive. He makes meaning out of the intimate connection between an HIV-positive analyst and his patients, he describes how the meaning of this experience differs from patient to patient yet vitally informs his work regardless, and he outlines how differences in the way he discloses information are analyzable and speak to the relational, the political, and the ethical domain. His work is an important contribution to the literature of psychoanalysis and sexual orientation. In writing about issues of illness, life and death, and intra-group difference among gay men, it forges past issues of sexual identity and bravely offers his own experience as valuable data for furthering the relational mission of psychoanalysis.

References

Belenky, M., Clinchy, B., Goldberger, N., and Tarule, J. (1986). Women’s ways of knowing. New York: Basic Books.
Ehrenberg, D. (1995). Self disclosure: therapeutic tool or indulgence? Countertransference disclosure. Contemporary Psychoanalysis. 31, 213-228.
Greenberg, J. (1995). Self disclosure: Is it psychoanalytic. Contemporary Psychoanalysis. 31, 193-205. Jordan, J. (Ed.). (1997). Women’s growth in diversity. New York: Guilford Press.
Mitchell, S. (1988a). Relational concepts in psychoanalysis: An integration. Cambridge MA: Harvard University Press.
Shabad, P. (2001). Despair and the return of hope: Echoes of mourning in psychotherapy. Northvale, NJ: Jason Aronson.

Reviewer Note

Andrew Suth

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